[Health behaviour and changes in health behaviour - are education and social status relevant?]. / Gesundheitsverhalten und Änderungen im Gesundheitsverhalten - welche Relevanz haben Bildung und Schicht?

BACKGROUND: Individual health behaviour counts as an important factor for health status. A healthier lifestyle substantially contributes to better health. People burdened with lower health and with lower socio-economic status could benefit notably. So far it is not known exhaustively to what extent education and social status contribute to changes in health behaviour and which motifs play a decisive role. METHODS: Based on cross-sectional data from the seventh wave of the "Gesundheitsmonitor", Bertelsmann Foundation, (n=1 436), the influence of social status and education on health behaviour and changes in behaviour was analysed. RESULTS: Specific health behaviour correlates with level of education and socio-economic status. In contrast, regarding health behaviour changes in the last 12 months prior to survey, no social class- or education-specific effect was found. Age, health status as well as fears and wishes in relation to health seem to be important causalities for changes of health-related behaviour. CONCLUSION: Interventions to foster healthy lifestyles should include class differences in specific health-related behaviour and personal reasons for behavioural changes.

[Social inequality and perceived quality of doctor-patient relationship among the chronically ill]. / Soziale Ungleichheit in der wahrgenommenen Qualität der Arzt-Patienten-Beziehung bei chronisch Kranken.

BACKGROUND: Several recent German studies indicate an association between social inequality and quality of health care, i.e., patients with a low socioeconomic position receive lower quality care than patients with a high position. In this study, we investigate whether two indicators of social inequality (education and income) are associated with the perceived quality of the doctor-patient relationship among chronically ill men and women. METHOD: Data basis is the TNS Health Care Access Panel (N=27 049). For the analyses chronically ill respondents were selected from the sample (N=12 343). In a multiple logistic regression analysis, odds ratios were calculated separately for men and women and for three age groups (18-30, 31-60, 61 years and older). We used three indicators for measuring the quality in the doctor-patient relationship: trust in physician, information received from the physician and participation in the decision-making process. RESULTS: Results show that income and education are consistently though weakly associated with the perceived quality of the doctor-patient relationship. Among chronically ill men and women with comparatively low income and educational level odds for rating the perceived quality of health care as suboptimal are slightly higher. This is especially true for the group of old chronically ill persons (61 years and older). DISCUSSION: Social inequality is associated with perceived quality of health care among chronically ill older men and women in Germany. These inequalities in health care can be explained by patient factors (e.g., information seeking, participation seeking) and physician related factors (e.g., providing information).

[Social factors influencing participation in self-help groups or organisations--results from selected questions for the health monitor]. / Soziale Einflussfaktoren der Teilnahme an Selbsthilfezusammenschlüssen--Ergebnisse ausgewählter Fragen des Gesundheitsmonitors.

OBJECTIVES: Using selected data collected by the Health Monitor (Bertelsmann-Stiftung) from 1,539 adults aged between 18 and 79 years this article describes which social factors have an impact on participation in self-help groups or organisations. Furthermore, questions about the length of participation, fields of self-help activity, and their usefulness were analysed. METHODS: All participants were approached in written form. The questionnaire included 103 health-related items (6 about self-help), and 15 demographic characteristics. The sample was weighted statistically by federal state, sex and age. RESULTS: 4.1% stated to be a member of self-help organisations for chronically ill or disabled people. On the whole, 9.1% have participated in self-help activities during their lifetime (currently active: 2.8%). Membership in self-help organisations increases with age, social class and according to personal involvement, whereas participation in self-help groups is quite different. The rate of participation of women is nearly twice as high as that of men (11.1 versus 6.9%). Generally, participation in self-help groups was also rated positively, but assessments vary with social class and the length of using them. CONCLUSION: Particularly with regard to the distribution of self-help participants depending on social class there are some discrepancies to other studies. These differences can supposedly be ascribed to methodical factors (e. g., social class index, sample size).

[Shared decision making]. / Shared Decision Making. Gemeinsame Entscheidungsfindung aus Patientenperspektive.

BACKGROUND AND OBJECTIVE: The demand for integration of patients in medical decisions becomes more and more obvious. Little is known about whether patients are willing and ready to share therapeutic decisions. So far information is lacking, whether existing communication skills of both -- patients and physicians -- are sufficient for shared decision making (SDM). This paper presents new data on patients perspectives regarding SDM. METHODS: Standardized survey of 3058 German speaking people (1565 females, 1493 males), aged 18-79 years, a population based random sample of an access panel (pool of german households available for specific surveys) regarding the following topics: medical decision making in practice, communication skills and behaviour of physicians. RESULTS: A majority of patients approved the model of SDM. However, some subgroups of patients, especially older patients, were less interested in the concept of SDM. Necessary communication skills which may help patients to participate in decision making were used rather scarcely. Patients who approved the model of SDM more often experienced a common and trustful exchange of information. CONCLUSION: Most patients favour the concept of SDM. The communication skills necessary for this process are to be promoted and extended. Research on patients' preferences and their participation in health care reform should be intensified. Academic and continuous medical education should focus on knowledge transfer to patients.

[Risks, chances and perspectives of restricting the free choice of doctors by patients]. / Risiken, Chancen und Perspektiven einer Beschränkung der freien Arztwahl.

Population surveys regarding free access to primary care physicians and medical specialists focus on selected aspects of public opinion. They are helpful but not sufficient in answering the relevant question: 'What are appropriate and efficient ways of access to the health care system?'. More important than survey results would be options for practical decisions by the patients themselves, based on a system offering different possibilities of choice. Competent piloting by 'gatekeepers' would need a problem- oriented and patient-centred medical education for primary-care physicians, starting during medical education and training and continuing throughout the professional medical careers. It should focus on three additional issues: New, alternative and unbiased ways of access to medical care should be developed, tried and evaluated to ensure beneficial use of the full potential of our health care system.

[Free choice of doctors - an international comparison]. / Die freie Arztwahl - ein internationaler Vergleich.

The focus of this international comparison concerning the issue of free choice among primary care physicians and specialists is to learn from experiences in other countries. Two different types of health care systems are analysed: state-administered health systems such as in Finland and Great Britain or competition-based systems such as in Switzerland and the USA. In the countries outlined mentioned and other OECD nations (Organisation for Economic Co-Operation and Development) not described in this study, several restrictions of free choice among physicians can be observed. Restrictions are to be found when changing the general practitioner as well as in first contact to specialists. Both limitations do not seem to have a significant effect on the level of satisfaction of the population with health care in general. From an international perspective free choice of doctors seems to be an exception in health systems.

[Free choice of doctors in Germany in retrospect]. / Freie Arztwahl in Deutschland - eine historische Perspektive.

Due to discussions on the cost and quality of health care and a new legislation on the German statutory sickness insurance system in 1999, the free choice of doctors has recently become topical. To assess its legitimation for the German health care system, its history and the groups of interest involved should be taken into consideration. Before the period of industrialization no homogeneous pattern of the medical profession existed. In case of illness individuals who lived within reach and were known for their competence in disease matters were approached. However, industrialization destroyed existing social networks, and establishment of new structures of health care in rural as well as metropolitan areas became necessary. The government approached this challenge by structuring medical education, passing regulations on the settlement of doctors and promoting the foundation of statutory sickness funds. The Health Insurance Law of 1883 established a mandatory insurance system for a broad array of industries. As it was the sickness funds' responsibility to provide sufficient resources for medical care, a sick member was tied to the physician under contract with his insurance. After a rapid increase in practising physicians at the end of the 19(th) century, doctors' organisations were eager to gain access to the new market segment of insurance members by calling for the free choice of physicians. The Leipzig association (Hartmannbund) was founded in 1900 to organize strikes of doctors in order to get their goals accepted. After 30 years of conflicts an appeasement was achieved by a presidential emergency law in 1931. It transferred the responsibility for the provision of sufficient health care resources from the sickness funds to the newly created body of the Association of Sickness Fund Physicians (Kassenärztliche Vereinigung) and determined the patients' free choice among licensed sickness fund physicians.